Comparison of the experience of caregiving at end of life or in
hastened death: a narrative synthesis reviewRESEARCH ARTICLE Open
Access
Comparison of the experience of caregiving at end of life or in
hastened death: a narrative synthesis review Jane Lowers1* ,
Melissa Scardaville2, Sean Hughes3 and Nancy J. Preston3
Abstract
Background: End-of-life caregiving frequently is managed by friends
and family. Studies on hastened death, including aid in dying or
assisted suicide, indicate friends and family also play essential
roles before, during, and after death. No studies have compared the
experiences of caregivers in hastened and non-hastened death. The
study aim is to compare end-of-life and hastened death caregiving
experience using Hudson’s modified stress- coping model for
palliative caregiving.
Method: Narrative synthesis of qualitative studies for caregivers
at end of life and in hastened death, with 9946 end-of life and
1414 hastened death qualitative, peer-reviewed research articles
extracted from MEDLINE, CINAHL, Web of Science, and PsycINFO,
published between January 1998 and April 2020.
Results: Forty-two end-of-life caregiving and 12 hastened death
caregiving articles met inclusion criteria. In both end-of-life and
hastened death contexts, caregivers are motivated to ease patient
suffering and may put their own needs or feelings aside to focus on
that priority. Hastened death caregivers’ expectation of impending
death and the short duration of caregiving may result in less
caregiver burden. Acceptance of the patient’s condition, social
support, and support from healthcare professionals all appear to
improve caregiver experience. However, data on hastened death are
limited.
Conclusion: Caregivers in both groups sought closeness with the
patient and reported satisfaction at having done their best to care
for the patient in a critical time. Awareness of anticipated death
and support from healthcare professionals appear to reduce
caregiver stress. The modified stress-coping framework is an
effective lens for interpreting caregivers’ experiences at end of
life and in the context of hastened death.
Keywords: Caregivers, Suicide, assisted, Grief, Motivation,
Systematic review
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* Correspondence:
[email protected];
[email protected] 1Emory
University, Palliative Care Center, 1821 Clifton Road, Suite 1016,
Atlanta, GA 30329, USA Full list of author information is available
at the end of the article
Lowers et al. BMC Palliative Care (2020) 19:154
https://doi.org/10.1186/s12904-020-00660-8
Background End-of-life caregiving frequently is managed by friends
and family, with an estimated 900,000 older adults re- ceiving care
from 2.3 million caregivers in the United States (U.S.) in 2011
[1], and rates of at-home death in Europe at 20–30% [2]. Caregivers
face challenges in managing patients’ needs and household tasks,
financial strain, and their own stress, anxiety, and exhaustion,
among others, over the course of weeks or months [3]. Other studies
have noted that end-of-life caregiving also carries potential for
rewards in terms of meaningfulness and opportunities for closeness
with the patient before death [4]. Multiple systematic reviews have
examined the
experiences and needs of end-of-life caregivers [3, 5– 12].
Although many individual studies are rooted in conceptual or
theoretical frameworks [13], few sys- tematic reviews have them as
an analytic structure: Broady [8] used personal construct
psychology as the basis for framework analysis, and Morgan [10]
con- ducted a feminist quality appraisal of gender in family
caregiving. In general, systematic reviews identify common concepts
of physical and emotional strain, stress, and feelings of
helplessness; commitment, meaning making, and satisfaction; and the
need for support and information [3, 5, 6, 8]. Hastened death
through aid in dying, including
assisted suicide and euthanasia, is available in parts of Europe,
North America, and in Colombia. To date, one systematic review
evaluated the experience of caregivers specifically in the context
of aid in dying (including assisted suicide and euthanasia) [14].
Studies of caregiv- ing during assisted dying describe caregiving
roles such as helping the patient navigate the medical and legal
hurdles to obtaining a lethal prescription, assisting with
preparation of the medication, bearing witness to the death, and
orchestrating the completion of patients’ wishes before, during,
and after death [15–20]. Compar- ing the experiences of caregivers
in aid in dying with those in other end of life trajectories can
inform practice for clinicians supporting patients and caregivers
before, during, and after hastened death. To date, no studies have
directly compared hastened death with end of life caregiving. This
review uses Hudson’s [4] conceptual model of
family caregiving for palliative care, which is based on Folkman’s
[21] stress-coping model and seeks to draw a comparison of
caregivers’ experiences during hastened and non-hastened death. In
the stress-coping model, caregivers confronted with an event, such
as a patient’s return home after a hospital stay, first appraise
the event. Events seen as a threat, challenge, or harm are met with
some coping strategy, either problem-focused or emotion-focused.
The event outcome may be
favourable or unfavourable, and the emotional outcome may be
positive, distressing, or some form of meaning- based coping that
informs future appraisals and coping approaches. Additionally,
variables such as caregivers’ sense of preparedness or the
patient’s disease status may mediate or moderate coping and
emotional responses. (See Appendix 1 for definitions of model
components.) Applying the model in end-of-life and hastened
death
literatures separately facilitates development of a rich synthesis
of caregiving within each context on its own and provides a rubric
for comparing them. Further, themes identified inductively in
either set of studies can provide insight into the strengths and
limitations of the model itself.
Methods This narrative synthesis is rooted in constructionism and
supposes that study participants, and researchers, build meaning
and shape reality through their interactions with the world and
with others. These created meanings are reflected in Hudson’s
conceptual model, in which caregivers identify, appraise, and
respond to events based on their own strengths or challenges.
Narrative synthesis can integrate diverse data against a
framework or theory [22] and is useful for exploring heterogeneity
across multiple studies [23]. This review follows Popay’s [22]
recommended steps:
developing a theory (in this review, Hudson’s model is the
theory)
developing a preliminary synthesis exploring relationships in the
data assessing the robustness of the synthesis
Review question and literature search The review question, “What
are the experiences of fam- ily and friends providing care at home
for a person at the end of life or in the context of the patient’s
hastened death?” can be broken into clearly defined population,
exposure, context, outcome, and study design (PECOS) criteria [23,
24] listed in Table 1. The review question further may be broken
down into
a series of subquestions that align with Popay’s steps as
follows:
What are the experiences of caregivers for patients at end of life?
(preliminary synthesis)
What are the experiences of caregivers of patients electing
hastened death? (preliminary synthesis)
In what ways are caregivers’ experiences similar or different at
end of life vs hastened death? (exploring relationships in the
data)
Lowers et al. BMC Palliative Care (2020) 19:154 Page 2 of 16
In what ways does the qualitative literature on end- of-life and
hastened death caregiving support or re- fute Hudson’s model of
caregiving experience? (assessing the robustness of the
synthesis)
The review included two sets of searches of Medline, CINAHL, Web of
Science, and PsycINFO — one for general end-of-life caregiving and
one for hastened death. The Boolean search terms are described in
Table 2. For parity between the two sets of data, the
searches
were limited to studies published between 1998, the year medical
aid in dying was legalised in Oregon, the first U.S. jurisdiction
to explicitly allow it, and April 2020. Searches were limited to
peer-reviewed literature pub- lished in English involving human
subjects. Additional studies were identified through citation
tracking in rele- vant systematic reviews identified in the search
process and in studies selected for inclusion.
Selection criteria Predefined inclusion and exclusion criteria
(Table 3) guided title and abstract review of the initial results
of each search and were the same for both searches. In addition,
full-text searching omitted studies in which caregivers’
experiences could not be separated from those of patients or
professionals, or studies in which current and former caregivers’
experiences were interwoven. All studies selected for full text
review were reviewed
using the Relevance, Appropriateness, Transparency,
and Soundness (RATS) Quality/Appropriateness Ap- praisal Tool [25]
to identify studies with limitations, such as unspecified
recruitment or analysis methods that could warrant concern about
the validity of the findings.
Analytic approach Using Popay’s [22] narrative synthesis approach,
par- ticipant narratives and author analysis in all studies in both
searches were coded first in NVivo (QSR Inter- national) using
thematic analysis to identify codes that fit within a priori themes
aligned with elements of Hudson’s model (such as appraisal, coping,
and event outcome, See Appendix 1: A Priori Codes), and sub-
sequently using inductive codes representing concepts not found in
the model (See Fig. 1). Each code was analysed separately in each
data set,
employing subcodes where needed to clarify multiple concepts (for
example, a favourable resolution could be getting needed services
or the patient having a peaceful death). The two pools of studies
were then synthesised individually within each theme of Hud- son’s
model as well as themes constructed outside the model. The two
synthesised data sets then were analysed side by side to identify
commonalities or differences. Where particularly illustrative,
quotes are included.
Results A search using the end-of-life caregiving term set (See
Table 2) yielded 9946 studies for review, with 5390
Table 1 PECOS Criteria
Population Family members or caregivers of adult patients with
life-limiting illness, through the point of death
Exposure Caring for an adult patient who is dying (life expectancy
< 3–6 months) or who chooses hastened death (medical aid in
dying, voluntarily stopping eating and drinking, euthanasia)
Context Caregiving in the home
Outcome Caregivers’ emotional, practical, and philosophical
experiences with caring for loved ones at end of life, either
because of illness or related to deliberately hastened death
Study Design Qualitative: interviews, focus groups, phenomenology,
ethnography
Table 2 Key Search Terms
End of Life Hastened Death
Population (Terminal* OR end-of-life* OR life-limiting OR cancer OR
palliative OR hospice) AND (famil* OR caregiv*)
(Terminal* OR end-of-life* OR life-limiting OR cancer OR palliative
OR hospice) AND (famil* OR caregiv*)
Exposure (for hastened death searches only)
N/A [[(aid* OR assist*) AND (dying OR suicide)] OR [hasten* death]
OR euthanasia OR [wish AND (hasten death OR die)]
Context Home Home
Outcome Belief* OR experienc* OR emotion* OR support* OR
need*
Belief* OR experienc* OR emotion* OR support* OR need*
Study Design Qualitative Qualitative
Lowers et al. BMC Palliative Care (2020) 19:154 Page 3 of 16
remaining after duplicates were removed (see Fig. 2). Two authors
(JL, MS) scanned the first 10% of titles independently and
conferred to refine the inclusion and exclusion criteria (see Table
3). After title review, 777 studies remained for abstract review.
The two authors again assessed the first 10% of abstracts inde-
pendently and conferred to further refine the inclu- sion/exclusion
criteria. Studies were limited to those capturing experiences of
bereaved caregivers who had cared for a patient through death at
home. Following abstract review, 140 studies remained for full-text
review; 40 studies met inclusion criteria. Finally, JL performed a
manual review of studies included in relevant systematic reviews to
search for possible overlooked studies, identifying two more and
bringing the total to 42 (See Fig. 2).
Searches using the hastened death term set (See Table 2) followed
the same review process, yielding 1414 studies for review, with
1117 remaining after duplicates were removed. One hundred nine
studies remained after title review, 13 after abstract review, and
seven after full-text review. Hand-searching of references from
those studies and relevant systematic reviews yielded five more,
for a total of 12 (See Fig. 3).
Overview of included studies Of the 34 end-of-life caregiving
studies, six were from Australia, seven from Canada, five from the
U.S., four from the United Kingdom, 10 from elsewhere in Europe,
one from Japan, and one from New Zealand (Table 4). Among the 12
hastened death studies, five
Table 3 Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Published in English Not about caregiver experience
Hospice or palliative care Case reports, personal essays
Life expectancy < 6 months
Qualitative, interview-based studies Patients under age 18
Patient elected hastened death (hastened death review only)
Quantitative
Patient elected hastened death (end of life review only)
Fig. 1 Modified Stress-coping Framework, modified from Hudson
(2003)
Lowers et al. BMC Palliative Care (2020) 19:154 Page 4 of 16
were from the U.S., four from the Netherlands, two from
Switzerland, and one from Canada (Table 5). Across both sets,
cancer was a frequent cause of patient death, along with motor
neurone diseases. Tables 4-5 list studies included in the
syntheses; findings from studies are presented according to
components of Hudson’s model in Tables 6-10. In Hudson’s model, the
process of appraisal, coping,
and resolution begins with identification of an event. Caregiving
at end of life was both a single overarch- ing event and the sum of
many smaller events. However, for end-of-life caregivers, events
focused on changes in patients’ needs, whereas in hastened death,
events primarily followed a predictable pattern of planning,
preparation, orchestrating the death, and tying up loose ends. The
results of the synthesis are presented in the context of Hudson’s
model from appraisal through outcome, followed by influencing
factors, and lastly by inductive themes not repre- sented within
the model.
Themes from the literature review using a priori themes from Hudson
Appraisal (Hudson) Appraisal is the caregiver’s initial assessment
of the environment (or an event) and whether it falls within or
beyond the caregiver’s resources. In studies on end- of-life
caregiving, events appraised as irrelevant rarely merit mention in
final study analysis (Table 6). End-of- life caregiving events
appraised as benign include those in which the patient appeared
content and comfortable, such as having guests or being bathed. For
both sets of caregivers, challenging events were those that tested
caregivers’ capacity but were important to carrying out their
commitment to caring for the patient. For end-of- life caregivers,
coping with escalating care needs despite
Fig. 2 PRISMA (Preferred reporting items for systematic reviews and
meta-analysis) flow chart describing the search process for end of
life caregiving
Lowers et al. BMC Palliative Care (2020) 19:154 Page 5 of 16
fatigue was challenging; reconciling their own ambiva- lence to aid
in dying challenged hastened death caregivers. Among end-of-life
caregivers, events perceived as
threats primarily concerned the patient’s well-being and could be
internal (the caregiver’s own preparedness and resources) or
external (unavailability of hospice or other support). However,
caregivers also perceived threats to themselves, such as the toll
of fatigue or conflicts from other family members with differing
views of care goals; or threats to the family, such as exposure to
the patient’s deterioration. Hastened death caregivers primarily
identified threats as things that jeopardised patient’s ability to
achieve his/her desired death: uncooperative physicians, incomplete
ingestion of lethal medication, or a difficult or pro- longed dying
process. For hastened death caregivers, the possibility of legal
consequences following the death and the potential for social
stigma, particularly
in Switzerland, were threats to their own well-being before,
during, and after the death. End-of-life caregivers identified
multiple sources of
harm, including disease progression, insufficient profes- sional
care, and the potential that being honest about prognosis would be
detrimental for the patient. In hastened death studies in Canada
and the U.S., events appraised as harms were those in which health
profes- sionals caused the patient to suffer more than necessary by
making hastened death more difficult.
Coping (Hudson) Coping includes the caregiver’s thoughts, feelings,
and actions in response to appraisal. In both sets of studies, the
logistical demands of caregiving require frequent problem-focused
coping, but the overarching activity of caregiving appears
motivated by emotion and concern for the patient (Table 7).
Anticipatory grief is common among end-of-life caregiving studies
but rarely discussed
Fig. 3 PRISMA (Preferred reporting items for systematic reviews and
meta-analysis) flow chart describing the search process for
hastened death caregiving
Lowers et al. BMC Palliative Care (2020) 19:154 Page 6 of 16
Table 4 End of Life Caregiving Studies
Authors Study design Number of Caregivers Patient Condition
Angelo, J 2014 [26] New Zealand Phenomenology 6 Not specified
Aoun, SM 2012 [27] Australia Thematic analysis 16 motor neurone
disease
Armstrong MJ, 2019 [28] United States Qualitative descriptive 30
Dementia with Lewy bodies
Bentley, B, 2016 [29] Australia Thematic analysis 12 motor neurone
disease
Carlander, I, 2011 [30] Sweden Descriptive 10 Not specified
Cipolletta, S 2015 [31] Italy Phenomenology 13 motor neurone
disease
Clukey, L, 2007 [32] USA Phenomenology 22 Cancer, heart disease,
chronic obstructive pulmonary disease, hepatitis
Clukey, L, 2008 [33] USA Thematic analysis 9 Not specified
Coristine, M, 2003 [34] Canada Content analysis 18 Breast
cancer
Dobrina, R, 2016 [35] Italy Descriptive phenomenology 114
Cancer
Dumont, I, 2008 [36] Canada Content analysis 18 Cancer
Fisker, T, 2007 [37] Denmark Phenomenology 8 Not specified
Glass, AP, 2016 [38] USA Case study 28 Alzheimer’s
Grbich, CF, 2001 [39] Australia Thematic analysis 12 Cancer
Hasson, F, 2010 [40] Northern Ireland Content analysis 15
Parkinson’s disease
Hasson, F, 2009 [41] Northern Ireland Thematic analysis 9 Chronic
obstructive pulmonary disease
Hisamatsu M, 2020 [42] Japan Grounded theory 13 Cancer
Hovland CA, 2019 [43] USA Content analysis 36 Dementia
Hughes, M, 2015 [44] Australia Thematic analysis 28 Not
specified
Johnson, A, 2003 [45] Australia Narrative exemplars 1 Not
specified
Kalnins, I, 2006 [46] Latvia Phenomenology 18 cancer, stroke, heart
disease
Linderholm, M, 2010 [47] Sweden Hermeneutic analysis 14
Cancer
Lyckhage, ED, 2013 [48] Sweden Phenomenological 6 Not
specified
Mangan, PA, 2003 [49] USA Constant comparison 15 Cancer
Mohammed, S, 2018 [50] Canada Grounded theory 61 Cancer
Mori, H, 2012 [51] Japan Framework analysis 34 Cancer
Ortega-Galán, 2019 [52] Spain Phenomenology 81 Not specified
Payne, S, 2015 [53] England Cross-sectional 59 Cancer, other
Robinson, C, 2017 [54] Canada Constant comparison 29 Cancer
Sheehy-Skeffington, B, 2014 [55] Ireland Thematic content analysis
16 Cancer, heart failure
Sinding, C, 2003 [56] Canada Grounded theory 12 Breast cancer
Stajduhar, KI, 2013 [5] Canada Secondary analysis of qualitative
data 114 Not specified
Stone, AM, 2012 [57] USA Constant comparison 35 Lung cancer
Strang, VR, 2003 [58] Canada Not specified 15 Cancer
Strauss S, 2019 [59] USA Discourse analysis 46 Not specified
Thomas, C, 2018 [60] England Cross-sectional 30 Cancer, other
Totman, J, 2015 [61] England Framework analysis 15 Cancer
Turner, M, England [62] England Secondary analysis 17 Cancer,
other
Vachon M, 2020 [63] Canada Phenomenology 22 Not specified
Warrier MG, 2019 [64] India Thematic analysis Motor neuron
disease
Wong, WK, 2009 [65] Australia Thematic analysis 23 Cancer
Wu MP, 2020 [66] Taiwan Grounded theory 22 Not specified
Lowers et al. BMC Palliative Care (2020) 19:154 Page 7 of 16
in hastened death studies. Rather, hastened death care- givers
described setting their own feelings aside for the finite time left
to focus on patient needs.
Event outcome (Hudson) Event outcomes are the caregiver’s appraisal
of whether the event’s results are consistent with his/her goals.
Caregivers in both groups frame their views on death in terms of
the patient’s wishes – such as avoiding suffering – regardless of
their own feelings (Table 8). In end-of- life studies, positive
events are those that involve the patient’s status, whereas events
can be viewed as un- favourable if they have negative consequences
for either the patient or caregiver. In most studies, hastened
death caregivers tend to view events in terms of the patient’s
goals rather than their own needs.
Emotion outcome (Hudson) Emotional outcome is the caregiver’s
reaction to the event outcome. In Hudson’s model, it can include
posi- tive emotion or distress, but also different types of
meaning-based reframing, such as setting revised goals, that can
inform future appraisal and coping. Being rec- onciled to the
patient’s death and helping the patient avoid unnecessary suffering
were tied to positive emo- tional outcomes or the ability to
reframe events posi- tively for both sets of caregivers (Table 9).
End-of-life caregivers who were unprepared for the death
found
caregiving more distressing, and the patient’s suffering also
caused distress for both groups. The grueling nature of long-term
caregiving also was distressing for end-of- life caregivers,
particularly when circumstances led to a feeling of letting the
patient or family down. For some hastened death caregivers, the
intentionality of the death led to distress. Thus, for both sets of
caregivers, a feeling of violating family or cultural expectations
about dying and caregiving led to distress.
Influencing factors Hudson lists 18 variables that can influence
caregivers’ experience (see Appendix 1 for definitions). Although
each is distinct and based on other research or concep- tual
models, they can be broadly clustered as:
Ability (preparedness, mastery, competence, self- efficacy)
Structure (social support, information, respite) Satisfaction
(rewards, meaningfulness, mutuality,
choice and commitment) Outlook (anxiety, depression, and
psychological
distress; positive emotion; optimism) Personal (cultural factors;
caregiver burden and
health; patient’s disease status, level of dependency, and duration
of illness; caregiver age, gender, socioeconomic status)
Table 5 Hastened Death Caregiving Studies
Author Study Design Type of Hastened Death Number of
Caregivers
Patient Condition
Albert, SM, 2005 [67] United States Not specified Patient wish for
hastened death
80 Amyotrophic lateral sclerosis
Back, AL, 2002 [15] United States Grounded theory
Physician-assisted suicide 35 Cancer, AIDS, neurologic, other
Buchbinder, M, 2018 [17] United States
Ethnography Medical aid in dying 19 Not specified
Buchbinder, M, 2018 [18] United States
Grounded theory Medical aid in dying 34 Cancer, amyotrophic lateral
sclerosis
Dees, 2013 [68] Netherlands Thematic analysis Euthanasia 31 Cancer,
neurologic, other
Gamondi, C, 2015 [19] Switzerland Grounded theory Assisted suicide
11 Not specified
Gamondi, C, 2018 [20] Switzerland Grounded theory Assisted suicide
11 Cancer, AIDS, neurologic, other
Georges, JJ, 2007 [69] Netherlands Statistical analysis of
interview data
Euthanasia or physician- assisted suicide
87 Cancer, amyotrophic lateral sclerosis
Holmes, S, 2018 [70] Canada Content analysis Medical assistance in
dying 18 Cancer, organ failure, neurologic
Jansen-Van Der Weide, MC, 2009 [71] Netherlands
Secondary analysis of interview data
Euthanasia 86 Cancer, other
Inductive analysis Euthanasia or physician- assisted suicide
26 Cancer, old age, neurological
Starks, H, 2007 [16] United States Inductive analysis Hastened
death 48 Not specified
Lowers et al. BMC Palliative Care (2020) 19:154 Page 8 of 16
Caregiver age, gender, and socioeconomic status were excluded from
this analysis because they were not pos- sible to tease apart in a
synthesis of multiple published works. End-of-life caregiving
studies had ability-related
codes more often than hastened death studies, possibly because the
duration of end-of-life caregiv- ing facilitated learning new
skills or gaining confidence in abilities (Table 10). Hastened
death caregiving, by contrast, was a one-time process with few
steps repeated and little precedent. End-of-life caregivers
frequently described exhaustion and
mentioned the value of respite, but hastened death caregivers did
not, perhaps because of the shorter timeframe or a choice to defer
their own needs until after the death. Many influencing factors
could be positive or nega-
tive. Social isolation and lack of information were stressful for
both end-of-life and hastened death care- givers. Meeting the
patient’s wishes was related to satisfaction in both groups, while
being unable to meet expectations for care was stressful. Hastened
death caregivers, particularly in the U.S. and Canada, often
described preparing for the death as communal,
Table 6 Appraisal
Appraisal End of Life Hastened Death
Benign The patient is content and comfortable [26, 32, 36, 45, 53]
The patient receives services that facilitate their goal of
hastened death. The death is peaceful [17, 18, 71].
Challenge Coping with escalating number and intensity of caregiving
tasks, patient’s decline, disruption in routine. Demands consistent
with caregiver’s sense of duty and commitment, but achievable [26,
30, 37, 38, 45, 47, 48, 53–58, 60, 64].
Planning and preparation, reconciling one’s own beliefs to help the
patient [15, 16, 68, 70]
Threat Events that could affect the patient’s well-being, either
internal (caregiver’s own preparedness and resources) or external
(availability of services). Events that affect caregiver’s
effectiveness, such as fatigue. Realisation of potential for death
[27, 33, 36, 37, 42, 45–51, 57, 58, 60–64, 66].
Patient denied access to hastened death; risk of incomplete
ingestion, difficult or prolonged death, legal repercussions after
death, social stigma [15, 16, 18–20, 68–72]
“He started taking it and apparently it tastes awful, and so
started gagging a little bit, and wanted to stop halfway. And we
had discussed before, once you start it, you have to do the whole
thing. So then we gave him alcohol. Ah, it was terrible...”
(Buchbinder et al., p. 5)
“And then you weren’t really sleeping because every few seconds
you’re waking up and going ‘is she still breathing, is she still
there?’”’ (Totman et al, p500)
Harm Disease progression, insufficient professional help, potential
to harm patient by being honest about prognosis [27, 29, 33, 36,
37, 41, 45–51, 56, 57, 61, 62]
Burden of secrecy about cause of death (Switzerland), inadequate
support from providers resulting in more difficult death (U.S.,
Canada, Netherlands) [16, 19, 20, 68, 70]
Table 7 Coping
Problem focused Solving logistical problems, learning new skills,
keeping household running, arranging help, focusing on patient
wishes, serving as gatekeeper [26, 30, 33–36, 38, 39, 45, 48, 46,
50, 51, 53–58, 65]
Planning and conducting logistics such as physician appointments or
filling prescriptions, planning events before, during and after
death, finding solutions for protracted or complicated dying [15,
16, 68, 70]
…caregivers offered practical support to assist patients with
ingesting, such as getting juice or alcohol to chase the medication
if the patient requested it, holding a cup, or keeping an eye on
the time. Timekeeping was an important component of the process
because patients were typically advised to ingest the medication
quickly so as to avoid losing consciousness before finishing the
lethal dose. (Buchbinder et al. 2018, p4)
“So I remember us sitting down and then dividing the tasks, like,
father doing the shopping, and my sister would do this, and I’d do
that....” (Strang & Koop, p.110)
Emotion focused Caregiving as an opportunity to show love, be
rewarded with closeness; frustration, sadness, or anticipatory
grieving [27, 32, 33, 36, 37, 42, 44, 45, 47, 51, 54–58, 60, 61,
63]
Overall focus on fulfilling patient’s desire to avoid prolonged
suffering; where hastened death was illegal or quasi-legal, moral
distress in trying to reconcile patients’ request for support with
own ambivalence or discomfort. In Switzerland, carrying the burden
of secrecy after death [16, 19, 20].“So you know it was just a
sadness that we couldn’t use
the time to talk, to really, that I couldn’t help her prepare for
her death.” (Sinding, p.158) “My brother was used to say: “you do
not have to be selfish, you
do not have to think only for yourselves… if I want to do this
thing is because I do not have solutions and I can’t bear it
anymore.” Ehm…he was saying that we were selfish because we wanted
to keep him alive… at all costs. Even in these conditions… so
inhumane.” (Gamondi 2015, p149)
Lowers et al. BMC Palliative Care (2020) 19:154 Page 9 of 16
and the death itself as sacred or beautiful, whilst those in
Switzerland were more likely to describe fear of stigma if the
cause of death were widely known. Most factors identified in
Hudson’s model could
either enhance caregivers’ experience or create add- itional
challenge. For example, patients who spoke openly about their own
decline and impending death relieved caregivers of feeling a need
to protect the
patient from the truth or hide their own acceptance of the coming
death; end-of-life caregivers for patients in denial expressed
distress about not wanting to dash the patient’s hopes. Healthcare
professionals are not listed as an influen-
cing factor in Hudson’s model, but their role is a frequent theme
in caregiving studies, either as sources of support and information
or representing failures of the
Table 8 Event Outcome
Favourable resolution
The caregiver has the skills and resources to solve a problem;
death brings an end to suffering or is consistent with patient
wishes; the caregiver has guidance or professional help in dealing
with post-death tasks [28, 33, 36–38, 45, 46, 50, 54, 56, 57]
Healthcare providers help plan for or carry out the death; the
caregiver finds the hastened death to be peaceful or joyful; loved
ones have a chance for closure; the patient avoids unwanted
suffering [15, 16, 66–70]
“We all toasted with the bourbon. Yep. And I mean, I haven’t been
around many dying people so I don’t have experience with how that
often goes, but this was joyful and peaceful, and it’s exactly what
he wanted.” (Buchbinder et al p5)
‘I feel maybe it’s hard to say but I knew the end would come and
really it was a release not only for me but for X, I knew it was
because it was very hard to watch him.’ (Hasson et al 2010,
p.733)
Unfavourable resolution
Professional help is unavailable or inadequate; the illness causes
family tension; caregiving demands are unrelenting; the death is
unexpected, and the caregiver feels unprepared [27, 34, 35, 42,
47–51, 53, 55, 56, 60]
Healthcare providers are unwilling to discuss hastened death; the
patient cannot achieve hastened death and suffers; in Switzerland,
the caregiver experiences ongoing distress about breaking social
norms to assist in hastened death [15, 57, 70]
No resolution Caregiver lives in state of constant vigilance;
caregiver cannot process or mourn the patient’s death [32, 40, 51,
60, 61]
Table 9 Emotion Outcome
Positive emotion
Satisfaction with overall caregiving; patient’s serenity with own
condition [45, 46, 49, 55–58]
Events that align with patient’s wishes [15, 17]
Distress Patient decline, conflict between exhaustion and
increasing patient needs, social isolation, breaking a promise to
the patient, family conflict [27, 29, 30, 36, 37, 42, 45–51, 53,
56, 57, 60, 61, 63]
Complicated dying, moral distress about patient choice to die [15,
17–20, 67–71]
“The ‘I-killed-my-mom thing’ is big, still. Because it’s the
truth—how do I come to some resolution around that?” (Starks et al,
p117)“There’s a point where you’ve done, you’ve gone overboard. You
hear
the 110% effort stuff; well I think it’s probably 180% effort…. You
just, you become a basket case.” (Sinding, p.157)
Positive reappraisal
Caring provides opportunity for growth, respect, closeness, or
strengthening family ties. Death allows patient to escape
suffering. Escalating need for care results in more clinical
resources [26, 36– 38, 44, 46, 48, 51, 53–57, 60–63, 65].
Clinicians who would not facilitate hastened death but were
supportive in other ways; in retrospect, hastened death seen as
right choice [15, 16, 18, 19, 70]
“I mean it’s so wonderful that you can give someone yourself. I
mean that’s a real thing to do. And that they’ll let you.”
(Sinding, p. 157)
Revised goals
Reducing hopes for patient’s future, deciding to encourage the
patient to “let go” to avoid further suffering, admitting patient
needs institution-based care [27, 28, 30, 32–34, 37, 38, 45, 46,
48, 53, 56, 59–63]
Putting own grief or ambivalence on hold to focus on patient’s
wishes, reconciling to idea of hastened death as better option than
disease trajectory or unassisted suicide [15, 18, 19]
‘I had to realize that this person was no [longer] capable mentally
or physically, and I had to take over the role of [parent] just
like you do, first it was like a 6 year old and then a 5 year old.’
(Clukey 2008, p312)
Spiritual beliefs
Taking comfort in a larger force to supply strength or determine
patient’s fate, taking comfort in an afterlife [27, 32, 33, 36, 40,
56, 58, 59, 61]
Spiritual or ritual elements, during or after death, add to closure
[16, 18, 19, 68]
Positive events
Events that eased suffering, allowed for closure, or provided humor
[26, 32, 33, 36, 50, 55]
In U.S. and Canadian studies, deaths were described as joyful,
sacred, or peaceful, with patients’ wishes achieved [16, 68, 70,
71].
Lowers et al. BMC Palliative Care (2020) 19:154 Page 10 of 16
health system to adequately respond to patient and caregiver needs
(Table 11).
Inductive themes: other factors Beyond the themes outlined in
Hudson’s model, other internal and external factors appear to
affect
caregivers’ experiences (Table 12). The structure of healthcare,
nationally or locally, affects whether homecare services or hospice
is available, whether specialised care for conditions such as motor
neurone disease is available, and whether patients and care- givers
can readily find out about services for which
Table 10 Influencing Factors
Ability (preparedness, mastery, competence, self-efficacy)
Knowing what to expect, being prepared for patient’s death, feeling
able to learn skills to meet new demands, taking pride in ability
to care, having relevant previous experience [26, 27, 29, 30,
32–38, 40, 41, 43–59, 61, 62, 65, 66]
Because caregivers had not facilitated hastened deaths before, few
reported ability-related fac- tors. Not knowing how to manage a
difficult hastened death was stressful [16, 17].
“I guess the only thing I wish is I think it would have been easier
if we could have had more knowledge as far as how to do it; it
would have been a whole ton smoother. And it ended up feeling
fairly desperate. ...I don’t remember it as being anything
negative, I just remember it as being exhausting.” (Starks et al
p.117)
“[Home palliative care physician] sat me down at one point, I think
the last visit before she died…. He told me what I might expect
and… That was invaluable.” (Mohammed et al p1232)
Structure (social support, information, respite) Lack of support
from friends and family, and lack of information about what to
expect in caregiving were closely related to caregiver isolation
and exhaustion. Caregivers acknowledged the importance of respite,
but more often in retrospect after death [26, 28, 29, 32–42, 44,
46–51, 54–62, 64, 66]. “In retrospect. .. my sister should have
been trained, or somebody, to actually watch me for two weeks. ..
you need to watch that caregiver and make sure she’s getting sleep
and actually has her wits about her.” (Mangan et al, p252)
Experience varied by jurisdiction: Swiss caregivers and U.S.
caregivers where aid in dying was illegal reported feeling isolated
by potential social stigma. Where hastened death was legal, some
caregivers found support from family and friends. Swiss caregivers
appeared to have adequate information about hastened death, but
U.S. caregivers did not always have information on how to handle
difficult deaths. Respite was not mentioned in hastened death
studies [15, 19, 20, 69].
“The impossibility to tell “look, he has died of assisted suicide…”
it was tremendous, it was sad.” (Gamondi et al 2015, p. 150)
Satisfaction (rewards, meaningfulness, mutuality, choice and
commitment)
Enhancing: fulfilling sense of duty, showing love, meeting
patient’s wishes, personal growth, being close with patient
Enhancing: being able to help patient enact wishes, being present
for aided death, helping avoid suffering, taking place in sacred or
celebratory event, engaging in communal act of planning and
conducting death [16, 20, 70]Challenging: feeling inadequate when
unable to
meet all patient needs, needing to respect patient’s perspective
[26, 27, 29, 32–41, 44–51, 53–66]
“When I got down there that morning this whole circle of her
closest people had done a ritual around this killing drug, this
beautiful ritual around it.. .. They were all in a circle with a
candle lit and they were emptying the capsules together and they
were being playful and just the most beautiful energy, loving and
making jokes and everything.. .. They prepared it in a very sacred
and light way.” (Buchbinder 2018, p8)
“I thought to myself, yeah, you’ve [wife] done things like that for
me, it’s my turn to help you out and look after you and support
you.” (Totman et al, p503)
Outlook (anxiety, depression, and psychological distress; positive
emotion; optimism)
Enhancing: satisfaction with performing well, feeling appreciated,
closure
Setting aside anticipatory grief to focus on patient, seeing
patients achieve wish of peaceful death and release from suffering
[17, 18, 70]
Challenging: Impending loss of patient, relentless burden of
caregiving, gradual loss of closeness with patient, not wanting to
harm patient’s optimism [26, 30, 31, 35–37, 41, 44, 46, 48, 49, 53,
54, 56, 58, 60–65]
Personal (cultural factors; caregiver burden and health; patient’s
disease status, level of dependency, and duration of illness;
caregiver age, gender, socioeconomic status)
Exhaustion from caregiving, balancing caregiving and other life
responsibilities, sense of duty to patient, patient’s acceptance or
denial of condition [26, 27, 29–40, 46–62, 64, 66]
Understanding patient’s current suffering, likely trajectory and
the inevitability of death, shared expectation that hastened death
would be more comfortable, lack of clarity about when hastened
death would be appropriate [15, 70, 72]
Lowers et al. BMC Palliative Care (2020) 19:154 Page 11 of 16
they are eligible. Costs of medication and equipment also can add
to caregivers’ burden. For hastened death caregivers, whether
hastened death was legal and whether information and support were
available affected moral distress and preparedness to facilitate a
comfortable death. Caregivers reported different fundamental
motiva-
tions for providing care. In addition to cultural norms and a
desire for closeness at the end of the patient’s life, some
end-of-life caregivers also expressed distrust of the healthcare
system, particu- larly hospitals, as motivation to care for the
patient at home. Whilst some caregivers saw the hospital as a
fallback solution if the patient’s needs became too great, others
saw the potential of sending the patient to the hospital as a sign
that they had failed at caregiving. Finally, grief affects
caregiving at the end of life.
Anticipatory grief was common among end-of-life caregivers. On the
one hand, coming to terms with the patient’s impending death was
associated with easier resolution of grief after death. On the
other hand, the weight of anticipatory grief could lead caregivers
to shut down their emotions or to seek distraction in the form of
tasks. In this respect, grief might affect whether caregivers take
a problem- or emotion-focused approach to events in either
group.
Discussion This theory-centered review uses Hudson’s caregiv- ing
model [4] as a structure for synthesising results of studies that
evaluated caregivers’ experiences in
caring for patients at home at end of life and in the context of
hastened death. Whilst many of the themes identified in analysis
fit consistently with the model, themes constructed inductively and
relation- ships across concepts suggest opportunities to refine the
model:
The role of healthcare professionals Healthcare professionals play
a major role in care- givers’ experience at end of life.
Professionals pro- vide knowledge, teach skills, take decision
making pressure off the shoulders of caregivers, offer sup- port
and validation, and can be a gateway to re- sources [3, 6, 7]. When
healthcare professionals are unavailable, do not fulfill promises
to take measures to relieve patient suffering, or do not support
care- givers’ assessment that the care is too much to han- dle,
caregivers often report feeling isolated. Meta- analyses of
caregiver studies noted that across many studies, caregivers
expected health professionals to take responsibility for developing
a trusting, support- ive relationship with families [3, 6]. For
some end- of-life caregivers, the regular presence of hospice staff
is a welcome, regular break in caregiving, and its loss is felt
after the patient’s death. In hastened death contexts,
professionals’ legal ability or personal willingness to discuss the
patient’s wishes and op- tions, and provide practical support,
contributed to caregivers’ reduced moral distress and increased
sat- isfaction that the patient’s wishes could be achieved. The
role of professionals is not highlighted in
Table 12 Other Factors
Structure of health care delivery
Availability, or not, of specialised services or at-home care
support, cost of care, so- cial policies supporting family
caregiving [34, 41, 46, 49, 55, 61]
Legality, or not, of hastened death [15, 19, 20]
Grief Variable acceptance of impending death, anticipatory grief
[27, 31, 32, 36, 37, 41, 46–48, 51, 60]
Acceptance of hastened death as better than suffering or prolonged
dying [19]
Table 11 Healthcare Professionals
Healthcare professionals
Enhancing: providing information about what to expect in
death
Challenging: lack of comfort in discussing or supporting patient’s
desire for hastened death [15, 16, 18–20, 69, 71]Challenging: lack
of care coordination or continuity, lack of empathy,
lack of specialised knowledge or services, lack of clarity about
available services, focus only on patient, disappearance of
services after death [27–37, 43, 46–54, 57, 58, 61, 62, 64]
Lowers et al. BMC Palliative Care (2020) 19:154 Page 12 of 16
Hudson’s model but might fall into either social sup- port or
information.
Healthcare policy Whilst some caregivers reported having their
needs anticipated well and addressed, others reported isola- tion,
stress, and in some cases financial strain as the patients’ needs
outstripped the support structures available [3]. For example,
family caregivers for patients with motor neurone disease in
Australia re- ported difficulty accessing community palliative care
services or support adequate to the increasing de- mands of the
disease [29]. These structural issues are distinct from the
availability or attitude of indi- vidual health professionals and
may be more relevant in countries with limited or inequitable
healthcare infrastructure as opposed to national health coverage
[11]. Categorised unmet needs in studies of palliative care
patients receiving services at home included transportation,
equipment, caregiving support, and respite, in addition to adequate
communication and information from professionals. However, a
system- atic review of quantative studies of caregiver experi- ence
found a lack of consistent, high-quality evidence that specific
services and programmes im- prove caregiver outcomes [13].
Certainty of death Acceptance and anticipation of patient’s death
ap- pears related to having less grief before and after death. In
hastened death studies, caregivers are ac- tively working toward
the patient’s goal of a peaceful death, whereas some end-of-life
caregivers are un- prepared or surprised by the death. Hudson’s
model is not end-of-life-specific, but grief may be a relevant
factor for caregivers when death is likely. Broady’s [8] scoping
review of caregiver literature notes that anticipatory grief may
encompass awareness of both the patient’s impending death and the
change in identity, away from caregiver, that will follow. The
analyses reveal similarities and differences
between caregivers’ experiences in end of life and hastened death
settings. Across studies, caregivers commonly sought closeness with
the patient and reported satisfaction at having done their best to
care for the patient in a critical time. Hastened death care-
givers were more consistently reconciled to the pa- tient’s death
and the belief that death was preferable to anticipated suffering.
Some but not all end-of-life caregivers reached this conclusion.
However, the de- liberate nature of hastened death may mean that
pa- tients choose likeminded caregivers more deliberately than in
situations where caregiving may not be ex- pected to lead to death
[14]. Unlike in studies of end-
of-life caregivers, physical exhaustion and burden were not
commonly reported among hastened death caregivers [14], possibly
because their scope of pre- paring for hastened death is
finite.
Strengths and limitations This review is the first to apply
Hudson’s model as a lens for synthesising literature on the
experience of caregivers at end of life. As such, the review also
evaluates the limits of Hudson’s model and identifies potential
refine- ments, such as the role of healthcare professionals as an
influencing factor, that could strengthen it. A major limitation of
synthesising qualitative stud-
ies against such a model is that they may use other analytic models
that may emphasise different aspects of caregiving. Further,
because each study represents data synthesised from participants by
the authors, salient aspects of Hudson’s model, such as the ap-
praisal of benign caregiving events, may have fallen out of the
earlier published work in favour of events that better aligned with
the authors’ own theoretical underpinnings. Applying Hudson’s model
against a full set of original data may better illuminate its
strengths and weaknesses. Analysis is further limited by the
unknown degree
to which studies have accurately represented the experiences of
participants; for example, whether caregivers in hastened death
shared completely with interviewers their emotional response to the
death. Limiting inclusion to English-language publications reduces
the comprehensiveness of the hastened death analysis. Research on
hastened death in the Netherlands, Belgium, Switzerland and other
coun- tries may be published in local languages. Future analyses
could take additional steps to secure multi- lingual sources,
including soliciting articles from other scholars in the
field.
Conclusion In both end-of-life and hastened death contexts,
caregivers are motivated by the desire to ease patient suffering
and may put their own needs or feelings aside to focus on that
priority. Hastened death caregivers’ expectation of impending death
and the relatively short duration of caregiving may result in less
caregiver burden relative to end-of-life caregivers. Acceptance of
the patient’s condition, social support, and support from
healthcare profes- sionals all appear to improve caregiver
experience. Hudson’s model is an effective lens for interpreting
caregivers’ experiences at end of life and in the context of
hastened death, although modifications such as the inclusion of
professional caregivers could strengthen it.
Lowers et al. BMC Palliative Care (2020) 19:154 Page 13 of 16
Appendix Table 13 A Priori Codes from Hudson Conceptual Model of
Family Caregivers for Palliative Care Event Change in environment
or patient status, e.g., new information, worsening of symptoms,
return home from hospital
Appraisal Determining whether event is relevant to caregiver or
patient’s well-being
Threat Event poses a threat to patient or caregiver well-being that
may be outside of caregiver’s capacity to address
Challenge Event poses a potentially surmountable obstacle within
caregiver’s capacity
Harm Event leads to direct harm to patient or caregiver
Benign Event is unlikely to change patient or caregiver status or
may improve it
Irrelevant Event has no bearing on patient or caregiver
status
Coping
Problem-focused coping Acting on oneself or the environment, such
as seeking information
Emotion-focused coping Changing the relationship to the
environment, or changing the relational meaning of the experience
to avoid stress
Event Outcome
Favourable resolution Outcome is consistent with goals and
values
Unfavourable resolution Outcome is contrary to goals and values,
such as harm
No resolution Situation persists without opportunity for
change
Emotion Outcome
Positive emotion Favourable resolution leads to satisfaction, end
of coping
Distress Unfavourable resolution of event leads to distress
Meaning-based coping Unfavourable or no resolution leads to
adapting one’s mental state to be able to respond to an event
Positive reappraisal Finding meaning in the event based on beliefs
and values
Revised goals Adjusting goals for situation to obtain control
Spiritual beliefs Activating spiritual beliefs to fuel emotion- or
problem-based functions
Positive events A satisfactory outcome to the event leads to
positive appraisal
Variables
Preparedness How ready the caregiver perceives being, regardless of
actual skill or knowledge
Mastery Sense of control and enhanced self-esteem through
overcoming a stressor, development of new abilities, very broadly
(not task-specific)
Competence Perception of self as adequate at caregiving
specifically
Self-efficacy Belief in one’s own ability to manage a situation.
Not an inherent trait but event- and task-specific
Anxiety, depression and distress Negative psychological effects of
ongoing caregiving demands
Social support Interactions with friends, family, coworkers. Can be
positive or negative, or absent.
Information Seeking information to assess problems and solutions.
Successful information seeking facilitates more effective
coping.
Rewards Satisfaction, positive emotional gains from caregiving,
such as receiving love from patient, seeing patient content,
feeling accomplished
Meaningfulness Caregiver sees role as worthwhile investment or
challenge
Positive emotions Feelings of happiness, satisfaction, recognition
as opposed to stress
Optimism Inherent trait that buffers caregiver against strains of
caregiving
Mutuality Gratitude and meaning and idea of reciprocity in
relationship with patient, closeness
Respite Activities or interactions outside of caregiving that
reduce stress and allow caregiver to recognise his/her own needs
and interests
Cultural factors Expectations about familial roles that shape
expectations of caregiving and influence stress and coping (e.g.,
duty or honour to care for spouse or parent)
Caregiver burden and health Physical, emotional, psychological,
financial, or social problems related to caregiving (e.g., lack of
sleep, numbed emotions, isolation)
Choice and commitment Making a conscious choice to take on
caregiving role
Patient’s disease, dependency, and illness duration
Patient’s physical needs, psychological aspects of illness, and own
recognition and outlook on illness
Caregiver age, gender, socioeconomic status
Unclear but possible relationships in response to caregiving based
on relationship status, age (physical ability), economics
Additional codes
External influences Legal, economic, or other structural factors
that shape the environment in which care is provided overall and
the caregiver’s options for providing care (e.g., insurance, sick
leave)
Grief Anticipatory or posthumous grieving
Lowers et al. BMC Palliative Care (2020) 19:154 Page 14 of 16
Abbreviations AIDS: Acquired Immune Deficiency Syndrome; CINAHL:
Cumulative Index to Nursing and Allied Health Literature; PECOS:
Population, Exposure, Context, Outcome, and Study design; PRISMA:
Preferred Reporting Items for Systematic Reviews and Meta-analysis;
RATS: Relevance, Appropriateness, Transparency, and Soundness
Quality/Appropriateness Appraisal Tool
Acknowledgments None.
Availability of data and material Not applicable.
Authors’ contributions JL analyzed and interpreted all data and was
the primary contributor to the manuscript. MS conducted data
analysis and refined the inclusion criteria. NP and SH contributed
to and reviewed the research design, oversaw analysis, and made
substantial contributions to the manuscript. All authors listed
have approved this version for publication.
Funding This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Ethics approval and consent to participate Not applicable.
Consent for publication Not applicable.
Competing interests None.
Author details 1Emory University, Palliative Care Center, 1821
Clifton Road, Suite 1016, Atlanta, GA 30329, USA. 2American
Institutes for Research, Atlanta, USA. 3Lancaster University,
Lancaster, UK.
Received: 5 August 2020 Accepted: 29 September 2020
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https://doi.org/10.1089/jpm.2019.0689
https://doi.org/10.1177/1049909120907601
https://doi.org/10.1177/1049909120907601
Abstract
Background
Method
Results
Conclusion
Background
Methods
Selection criteria
Analytic approach
Overview of included studies
Themes from the literature review using a priori themes from
Hudson
Appraisal (Hudson)
Coping (Hudson)
Healthcare policy
Authors’ contributions
Consent for publication